1. Clear form Print Form
Utah State Tax Commission
210 N 1950 W • SLC, UT 84134 • www.tax.utah.gov TC-69C
Notice of Change Rev. 4/09
for a Tax Account
Read the instructions at the bottom of page 2 before filling out this form.
1 — General Information
1a. Social Security Number (SSN) Federal Employer Identification Number (EIN)
(required for individual sole proprietor) (required for all entities other than sole proprietor)
1b. Existing Tax Account Number(s)
(required for all accounts)
CPT
Corporate Tax:
STC
Sales Tax:
Withholding Tax: WTH If you do not have a
14-character account number,
enter your six-character
WMP
Mineral Prod. Withholding: account number.
Daytime phone number
1c. Name of Business Entity or Sole Proprietor - PRINT
Owner's street address Cell phone number
City County State ZIP code
2 — Account Changes Mark all boxes that apply.
2a. Close account (mark all that apply): Sales tax Transient room tax Motor vehicle rental tax
Restaurant tax Waste tire recycling fee Mineral prod. W/H tax
 Effective date: __ _ _ _ _ _
______ Withholding tax
NOTE: Do not use this form to close a corporation. A corporation must withdraw or dissolve through the Utah Dept. of Commerce.
2b. Change address (mark all that apply): Corp. Tax Sales tax Withholding tax Mineral prod. W/H tax
New address
Head office
Physical location City County State ZIP Code
Mailing address
2c. Change phone number (mark all that apply): Corp. Tax Sales tax Withholding tax Mineral prod. W/H tax
New phone number: ____________________________

2d. Change email address (mark all that apply): Corp. Tax Sales tax Withholding tax Mineral prod. W/H tax
New email address: ____________________________

2e. Change DBA/Business name: Mark here and attach Dept. of Commerce Articles of Incorporation
2f. Add/remove officer/owner: Mark here and attach Dept. of Commerce Change Form.
• Provide the officer/owner’s SSN: _ _ _ _ _ _ _ _ _ _
__________
2g. Other: Mark here and explain:
Continued on next page

2. 3 — Sales Tax Outlet Changes Attach additional sheets in this format if necessary.
Use Section 3 of this form to report CHANGES to EXISTING sales tax outlets. To add NEW outlets, use form TC-69B.
Current physical street address for this sales tax outlet USTC assigned outlet number (printed on TC-62A & TC-62AG)
City County State ZIP code
Close sales tax outlet Effective date:
Change phone number:
Other:
Current physical street address for this sales tax outlet USTC assigned outlet number (printed on TC-62A & TC-62AG)
City County State ZIP code
Close sales tax outlet Effective date:
Change phone number:
Other:
4 — Authorized Signature
Signature of Authorized Applicant or Owner (Application will not be accepted without signature) Date
Sign and date here before you mail or fax form.
SIGN HERE
IMPORTANT: To protect your privacy, use the quot;Clear formquot; button when you are finished. Clear form
Notice of Change for a Tax Account
Use this form to report changes for: Section 2 Use Section 2 to report changes to your main tax
account(s). Give complete information.
• an existing corporate tax account
Section 3 Use Section 3 to report changes to single sales
• an existing withholding tax account
outlets/locations, such as closure or a new phone
• an existing sales tax account number.
• existing outlets for a sales tax account Section 4 Sign and date. We will not process this form
without an authorized signature.
• an existing mineral production withholding account
To register a new business, use form TC-69. To report new
Return this form to :
outlets for an existing sales tax account, use form TC-69B.
Master File Maintenance
Instructions Utah State Tax Commission
210 North 1950 West
Section 1 Fill out this section completely. This information
Salt Lake City, UT 84134-3310
identifies and confirms your tax account(s).
or fax to 801-297-3573